How The Health Care Repeal Push Marks The End Of The Universal Health Care Consensus

Here's one case for the individual mandate in the health care law boiled down to two sentences -- both fairly elegant considering they were spoken extemporaneously.

"There isn't anything wrong with it, except some people look at it as an infringement upon individual freedom. But when it comes to states requiring it for automobile insurance, the principle then ought to lie the same way for health insurance, because everybody has some health insurance costs, and if you aren't insured, there's no free lunch. Somebody else is paying for it." -- June 14, 2009

A corollary to that argument is that you can't have a functioning private health care system that treats the sick unless it also draws money from the healthy. In this regard, the individual mandate actually marries two distinctly American priorities -- an obsession with private markets, and the core belief that nobody should go without health care.

Considering just how cacophonous the health care debate has become, it might surprise you to learn that the mystery reformer quoted above is Sen. Chuck Grassley (R-IA), the Republicans' health care point man in the Senate who, during the same interview, with great authority, claimed "I believe that there is a bipartisan consensus to have individual mandates."

Two months later he threw in his lot with Sarah Palin (R-AK) and the Death Panelers. Now he claims -- along with about half the attorneys general in the country -- that the individual mandate is unconstitutional and, like the rest of the GOP, uses it as the foundation for a far-reaching political assault on the health care law.

Today, the public debate over the health care law is held on decidedly Republican-friendly terms: Did the Democrats violate the constitution? Did they encroach upon your liberty? Did they take over the health care system and place themselves between you and your doctor?

Obscured by these pseudo-populist theatrics, though, is a reality that's a lot friendlier to Democrats than they realize. Grassley's violent lurch to the right wasn't idiosyncratic. It was the consequence of a deliberate Republican political strategy that made supporting "Obamacare" impossible, even for the remaining few moderates in the GOP. What was once a popular, if not consensus, policy framework on the right -- authored by personal-responsibility conservatives and popularized by John Chafee, Bob Dole, and Mitt Romney -- rapidly became kryptonite for Republican politicians. As a result, for the first time in more than a half century, there is one political party in the country that has zero high-profile advocates for a forgotten goal: that somehow, some way, every citizen deserves proper health care.

And yet they can't quite bring themselves to say that.

"I've said before I think getting at affordability is the key to universal coverage," said Dave Camp, the Republican Chairman of the House Ways and Means Committee, which has broad authority over health care policy. "If we can take the beginning steps to reducing health care costs, to affordability, I think you'll see more and more Americans buy insurance."

I asked Camp how to do that without a mechanism -- like the mandate -- to assure that coverage is indeed universal. His response was to pivot to a criticism of the mandate in the existing health care law.

"This mandate is a false mandate," he said. "I mean now with more than 100 wavers that have been granted to unions and businesses and other organizations, I don't know who this bill is going to apply to frankly."

That raises at least one question: How, if the mandate is so innocuous, can it also be such a great affront to liberty? But it doesn't get the GOP any closer to answering a more important question: is universal coverage a Republican goal at all, and, if so, how do we get there?

I put that question to a number of leading Republicans. Not one claimed universal coverage was a goal of Republican policy, and from their answers it's clear that universal health care is an afterthought.

"Our goal is the same today as it was at the health care summit, as we said to the President. We asked him to work with us on specific steps to lower health care costs so that people could afford to buy insurance," said Sen. Lamar Alexander (R-TN). "Our goal is to lower the cost of health care. We believe the best way to do it is step by step."

"I think the goal is optimum coverage but achieved in a different way than the way [Democrats] do it," said Sen. John Thune (R-SD), a likely GOP presidential candidate. "There's a whole bunch of prescriptions which you've heard us talk about in the past, including buying insurance across state lines. But there's also Tom Coburn, Richard Burr, others working on some innovative stuff on the tax codes, and basically providing tax equity when it comes to whether you derive your coverage through your employer or buy it in the market place, and giving people a tax credit to buy their own health care."

Almost all Republicans now say they hope to make insurance cheaper so that more people can afford it, but the implication is that people will be left behind.

"I mean, you can cover virtually everybody," Thune said. "I don't think there's anything I've seen that covers everybody -- but you can get close to it."

"It's fair to say it's pretty clear what our alternatives were, which would be to empower individuals to make choices, to make health care more affordable for more people, including small businesses," said Sen. John Cornyn (R-TX), whose job as NRSC chairman is to get Republicans elected in an environment where the party's base is becoming more conservative.

"The problem is -- now, of course, everybody has access to the emergency room, whether they can pay or not, but it's not particularly cost effective, it's not particularly efficient, and it doesn't deal with preventative care and things like that," Cornyn said.

Now that Republicans control the House of Representatives, their fusillade against the health care law has actual legislative ammunition. But the question of what they'd replace it with is still open.

"We'll let the committees do their work on how we should replace this, and what the common sense reforms will be. They'll have hearings. It'll be a bipartisan process," said House Speaker John Boehner (R-OH). We'll see what they come back with."

What they came up with last time around -- their alternative to the Affordable Care Act -- was a grab bag of industry-friendly and anti-federalist ideas: malpractice reform, allowing people to buy insurance across state lines. The outcome, according to congressional actuaries, would be roughly no decrease in the number of uninsured people, when you adjust for population growth. "By 2019, CBO and JCT estimate, the number of nonelderly people without health insurance would be reduced by about 3 million relative to current law, leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, roughly in line with the current share."

Once upon a time, that famous liberal Richard Nixon proposed a universal health care plan to blunt the push for single-payer health care. Years later, leaders of that same party authored a plan that looks a lot like Romneycare, which looks a lot like Obamacare. Those days are over.

About The Author

Brian Beutler is TPM's senior congressional reporter. Since 2009, he's led coverage of health care reform, Wall Street reform, taxes, the GOP budget, the government shutdown fight and the debt limit fight. He can be reached at brian@talkingpointsmemo.com